Introduction: firearm violence crisis in the United States

The United States is experiencing its worst firearm violence rates on record. Nearly 40,000 Americans die and 85,000 more are injured each year due to firearm-related causes (Centers for Disease Control and Prevention, 2024). In 2020, 45,222 Americans died due to firearm-related deaths including interpersonal violence, suicide, and accidents, which is approximately 124 people dying from a firearm-related injury each day (Centers for Disease Control and Prevention, 2024). Furthermore, the number one cause of pediatric mortality in the United States is now firearm injury (Kaiser Family Foundation, 2024). In response to these alarming rates of firearm violence, the American Medical Association (AMA) has declared firearm violence a public health crisis, signifying an urgent need for physician competency in firearm safety patient counseling and acute firearm-injury care (American Medical Association, 2024). In recognition of this need, the American Medical Student Association (AMSA) created the Medical Students for Gun Safety Coalition; however additional initiatives are necessary to enhance physician training on the topic of firearm violence to mitigate firearm morbidity and mortality (American Medical Student Association, 2024).

The role of physicians in addressing firearm morbidity and mortality

Physicians play a crucial role in treating firearm-related morbidity, including handling acute firearm-related traumas and reconstructing firearm-related injuries (Safeek et al., 2023; Meade et al., 2021). However, physicians can also play a considerable role in preventing firearm-related mortality, including addressing psychiatric illness that may predispose persons to committing acts of firearm violence or suicide, and counseling patients regarding firearm safety. With appropriate training, physicians are empowered to impact outcomes; thus, it is imperative that physicians receive specific training on how to counsel patients about safe firearm storage, as well as how to counsel firearm owners undergoing mental health crises, as firearm ownership poses a significant risk for death by suicide (Miller et al., 2007).

Physician advocacy can also play a critical role in preventing firearm violence. Physicians hold societal power and influence that well-position them to advocate for structural support and prevention policy. Examples of physician-led advocacy include the CanMEDs framework, which includes health advocacy as a fundamental competency for Canadian physicians and specifically calls for physicians to “support the mobilization of resources to effect change” and the Accreditation Council for Graduate Medical Education includes advocacy as a core competency under “Systems-Based Practice” (Royal College of Physicians and Surgeons of Canada, 2024; NEJM Knowledge+, 2024).

Embracing firearm violence prevention and advocacy in medical school curricula

Few medical schools broach the topic of firearm violence prevention in their curricula or embrace medical student advocacy as a means to policy/systemic change. Within the medical education literature there have been multiple calls to action, further demonstrating the need for medical schools to integrate firearm violence prevention training into medical school curricula (Barron et al., 2022; Gondi et al., 2019). As medical students progress through their education, it is important to foster opportunities for them to identify as effective change agents, as this prioritizes advocacy as a key component of their physician-professional identity.

Given the alarming rates of firearm violence in the United States, there is a pressing need for the rising generation of physicians to develop an adequate knowledge base around: 1) counseling patients on firearm safety and 2) how to treat acute firearm-related injuries, e.g., packing gunshot wounds (GSWs) and acute hemorrhage control. However, the density of material in the medical school curricula presents a potential barrier to incorporation of these topics. The traditional medical school curriculum is heavily laden with learning the intricacies of the basic sciences and priming of bedside manner and clinical skills. This leaves limited room for addition of novel topics to an already saturated curriculum.

Recent publications emphasize the importance of implementing firearm prevention curricula in medical schools and describe the substantial lack of content; one publication noted only 13–18% of schools participating in the AAMC curriculum inventory documented curriculum efforts (Barron et al., 2022). A systematic review found only four training programs that included firearm safety trainings for health care providers and appealed for an increase in training efforts (Gondi et al., 2019). Studies of training methods for student advocacy and community engagement as key prevention strategies are lacking. Therefore, it is necessary to assess medical student willingness to participate in learning activities on the topics of firearm safety and firearm violence prevention, as well as feasibility of adaption of these topics by faculty into the curriculum. In response to this growing need, we developed and evaluated a novel firearm violence initiative for medical students emphasizing skill development, advocacy, action, and community stakeholder engagement to support firearm violence prevention training in undergraduate medical education.

Gun* Violence Prevention Week: a novel firearm violence initiative for medical schools

In 2020, first and second-year medical students at the University of Louisville School of Medicine (ULSOM) developed GunFootnote 1 Violence Prevention Week (GVPW) to achieve the following goals:

  • increase awareness about firearm injury/death,

  • teach medical students applicable patient counseling skills to facilitate secure firearm storage,

  • practice risk assessment interviewing for firearm-related suicide,

  • practice packing wounds/applying tourniquets, and

  • provide opportunities for policy advocacy.

Several firearm injury survivors shared personal narratives about the impact of firearm violence on their lives, alongside a panel of trauma and neurosurgeons who shared the impact firearm violence has had on their lives and careers. These diverse topics were intentionally chosen to provide introductory content for multiple aspects of firearm prevention training domains. All Health Sciences Campus students, residents, faculty, and staff were invited to attend. A detailed outline of GVPW is provided in Table 1. Here, we describe an exploration of the reactions of participants and trends in feedback in hopes of informing the further development of firearm violence prevention curriculum.

Table 1 Gun Violence Prevention Week sessions, activities, and significance.
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Post-session surveys were created by medical students to evaluate:

  • prior training in the topic (yes/no),

  • most/least useful parts of the session (open text),

  • future intentions following GVPW (multiple choice/open text),

  • hopes for future topics (open text),

  • if they view themselves as agents of change (yes/no),

  • plans to engage with community organizations in the future (yes/no),

  • if the session changed their knowledge (yes/no), and

  • an open response opportunity to share any overall comments.

Attendees of the event were invited to complete post-session surveys following each session via QR codes that appeared on presentation screens following each session. Post-session surveys were identical. Participants were prompted to select the specific session they had attended prior to completion and to identify their role (e.g., medical student, faculty, etc.).

Survey data was analyzed using descriptive summary statistics. Qualitative responses were coded independently by two authors [RS and KU] and themes were constructed using thematic analysis framework (Braun and Clarke, 2012). Patterns in the qualitative text responses were noted and must have independently emerged for both coders to be included in the results.

Implementing firearm violence prevention into the traditional medical school curriculum

There were 280 total attendees at GVPW, and 158 total participants completed post-session surveys (all sessions combined). Medical students represented 77% (124 /158) of post-session respondents. Response numbers varied for each session and/or specific survey question. Many participants (69% 109/157) reported they had received no training prior to GVPW and 91% (117/128) reported that the sessions changed their knowledge. “Counseling firearm owners on firearm safety” was the most selected response (69% 85/122) when asked about future intentions following GVPW, 76% (95/124) responded “yes” when asked if they will engage with prevention-focused community organizations following GVPW, and 97% (126/130) agreed that they now view themselves as agents of change. Multiple respondents noted the most useful part of GVPW was being able to practice skills, especially during “Stop the Bleed” training, the open dialog about the role physicians play in firearm violence prevention, and the benefit of learning directly from the community. Three overall themes were agreed upon from open-text analysis and are discussed in Table 2, with sample direct quotes supporting each theme.

Table 2 Participant feedback on GVPW outcomes.
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Future impact: the development of a firearm violence prevention curriculum for medical schools

Physicians are uniquely situated to integrate firearm violence prevention counseling into routine clinical care. The impact of the evidence-based prevention training in medical schools has been documented. For example, long-term impacts of Opioid Overdose Prevention and Response Training with medical students demonstrated sustained knowledge and attitude changes at 6 months (Moses et al., 2022). Studies have documented the impact of training programs that assist students with gaining confidence in providing diabetes management education and support (Fazel et al., 2017). These same approaches to prevention can be applied to firearm violence prevention. An elective approach to incorporating this content is not the ideal curricular strategy as the prevalence of firearm violence in the United States impels us to ensure our entire physician workforce strengthens capacity for prevention. Medical schools may avoid adopting firearm violence prevention and advocacy curricula due to fear that the topic is political. We suggest that medical schools shift the focus to evidence-based approaches to reducing firearm-related injury and death. The GVPW curriculum explicitly focused on clinical skills and student-initiated advocacy steps and did not inherently endorse any specific legislative agenda.

We suggest partnering with organizations that take a non-partisan approach in advocacy efforts such as Whitney/Strong, which advocates for legislation that temporarily separates persons from their firearms if there is risk of harming self or others (Whitney/Strong, 2024). Further, we recommend highlighting personal stories and human connection regarding ways in which firearm violence directly impacts individuals, communities, and practicing physicians as impetus for commitment to action. Finally, it is critical to facilitate discussion around societal contributors to firearm violence such as structural injustice, lack of social support and access to mental health care, as well as how to become involved in advocacy at both clinical and policy levels. We also suggest partnering with other disciplines and departments specifically trained in suicide and homicide prevention, such as social work and psychiatry, to develop evidence-based clinical skills counseling content, as well best practices for physicians, when they find themselves in “duty to warn” situations. The role of appropriate referrals to mental health specialists can be challenging for experienced physicians; therefore, providing space for the future physician workforce to reflect on these specific scenarios could be useful for prevention. Our GVPW demonstrated that students and faculty are open to this content and these conversations and can set aside politics for the greater cause of preventing firearm violence.

Our evaluation of GVPW is limited by lack of outcomes regarding actual application in clinical environments and inability to compare pre/post-session changes. Still, our experiences helped us gain momentum and inform direction in the initiation of a preliminary required, longitudinal firearm violence prevention curriculum with the goal of:

  1. 1.

    highlighting the importance of physician involvement in preventing firearm violence,

  2. 2.

    teaching medical students practical firearm safety patient counseling, including proper storage of firearms for suicide prevention,

  3. 3.

    specific clinical skills training for firearm-related injuries and trauma, and

  4. 4.

    advocacy-related approaches to addressing firearm violence, including drafting policies, and meeting with legislators (Table 3).

    Table 3 Proposed University of Louisville Firearm Violence Prevention Curriculum with Integration to Normalize Firearm Violence Prevention Training as Essential.
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The proposed curriculum was approved by our Educational Program Committee with development and implementation taking place over proceeding academic years. Our process of progress could be applied to the development of other prevention efforts at other medical schools.

Medical students typically spend their first 2-years engaged in didactic study. While clinical exposure is limited, students are primed for their clinical encounters with the incorporation of standardized patients, simulating true patient encounters, while receiving feedback on their communication skills. Prior to completing their sessions, students are lectured on topic-specific communication strategies, e.g., smoking cessation. At ULSOM, firearm safety counseling will be addressed similarly through incorporation of a standardized patient case with accompanying pre-lecture.

The practical skills gained from the STOP THE BLEED training are easy to implement and can be taught in a short, 1-h training session, as demonstrated by the 1-h session conducted during the lunch hour during GVPW. At ULSOM, STOP THE BLEED trainings are being adapted for medical students and incorporated alongside Basic Life Support (BLS) training.

The humanistic component is often underscored through clinical encounters, but empathy for those affected by firearm violence can be emphasized through patient panels, in which survivors of firearm violence share their stories. In our evaluation, we found that at least four students reported an empathetic response, citing the stories of those surviving GSWs as a primary motivator to become more involved in gun violence prevention work.

Some GVPW attendees expressed concern regarding speakers’ contrasting firearm ownership values, with some expressing no firearms is best and others disclosing owning firearms themselves. Hence, it is important to openly acknowledge that there are multiple opinions on this topic. These varied opinions should not be cause for avoidance or detract from training. The reality in America is that most physicians will work with patients who own firearms. A public health approach to medical training that is evidence-based and focused on harm reduction should be prioritized.

Some medical schools have successfully implemented specific firearm prevention trainings using interactive case scenarios and standardized patients to provide clinical skills feedback with plans to expand to other learners across undergraduate and graduate medical education (Rickert et al., 2022). A longitudinal curriculum should be an aspirational, yet feasible goal for all medical schools. An advisory group of national experts have published a robust, data- and consensus-driven roadmap of priorities for health professions education on firearm injury that includes patient-centered care educational priorities with the hopes of creating a pathway to clinician competence (Hoops et al., 2022). Medical schools may still be challenged to find the curriculum hours in an already demanding and crowded curriculum; thus, a one-week event such as our GVPW can be an essential first step to gather champions and be a catalyst for deeper discussions that lead to comprehensive development, curriculum integration, and action. Our communities are suffering deeply from significant firearm violence; may we respond by committing to train the next generation of physicians in firearm violence prevention.